Cholelithiasis

case study on patients suffering from Cholelithiasis

1. CHOLELITHIASIS

2. Gall bladder Gall bladder is a pear shaped hollow organ located just below the liver in the right abdomen. Functions : Store & concentrate the bile. Alteration of bile. Helps in fat digestion.

3. CHOLELITHIASIS Formation of gall stones.

4. Clinical presentation DEMOGRAPHIC DATA AGE : 36 Yrs D.O.A : 29/04/2019 D.O.D : 03/05/2019 NO.OF HOSPITAL DAYS : 5 days ROOM NO : 1511

5. Medical History PAST MEDICAL HISTORY: S/P Lower segment caesarean section (LSCS) in 2012 & 2019 (January). S/P Right breast incision and drainage in 2012.

6. PRESENT COMPLAINTS P2L2 with H/O of gall stones. Case of upper abdominal pain more in right hypochondrium region. One episode of vomitting on 28/04/19. PROVISIONAL DIAGNOSIS: Cholelithiasis with dilated common bile duct

7. LAPAROSCOPIC CHOLECYSTECTOMY Surgical procedure to remove gall bladder. It is recommended if patients have Cholelithiasis Choledocholithiasis Cholecystitis Pancreatitis

8. Anthropometric Data Height : 162 cm Weight : 52 Kg Body Mass Index : 20 Kg/m2 (WHO) (BMI) classification : N ormal weight (18.5-24.9) Ideal Body Weight : 62 Kg ( B roca Index) (IBW)

9. Blood parameters PARAMETERS NORMAL VALUE 30/04/19 01/05/19 Haemoglobin 12.5 - 16 % 12. 9 12.6 Platelet 150 - 400 thou/UL 362 306 Bilirubin Total 0.3 – 1.2 mg/dl 1.26 1.01 SGOT 0 - 37 I.U/L 449 129 SGPT < 34.0 I.U/L 446 314 Alkaline phosphatase 100 - 290 I.U/L 262 226 Total protein 6 - 8 g/dl 8.4 - Albumin 3.5 - 5.0 g/dl 4.0 3.7 globulin 1.8 - 3.6 g/ dl 4.4 4.3

10. Subjective Assessment Tool (SGA) No weight loss - 1 Sub optimal solid diet - 2 No GI symptoms - 1 Functional capacity (none) - 1 Co- morbidity ( Healthy) - 1 No decreased fat store or - 1 Subcutaneous loss No signs of muscle wasting - 1 SCORE : 8 WELL NOURISHED

11. Nutrient Requirements Energy : 1,550 Kcal Carbohydrates : 320g Protein : 40g Fat : 10g

12. Nutritional Review DATE RECOMMENDED DIET ENERGY (KCAL) PROTEIN (G) 30/04/19 CLEAR LIQUID DIET 600   01/05/19 NPO - - 02/05/19 FAT FREE SOFT DIET 1400 40 03/05/19 FAT FREE SOFT SOLID DIET 1400 40

13. 1 DAY OF ADMISSION : CLEAR LIQUID DIET TIMING MENU QUANTITY ENERGY (Kcal) CHO (g) PROTEIN(g) FAT (g) 6 AM TENDER COCONUT WATER   200ml 30.59   6.32   0.52   0.32 8 AM TROPICANA APPLE JUICE   200ml   94   22.9   o.4   10 AM VEGETABLE SOUP   200ml   98   12   4.1   4.4 12 PM RICE KANJI   200ml   142   53.9   5.3   0.4 2 PM CLEAR SOUP   200ml   86   10.6   3.1   0.4 4 PM BLACK TEA   200ml       6 PM RICE KANJI   200ml   142   53.9   5.3   0.4 8 PM TENDER COCONUT WATER 200ml 30.59   6.32   0.52   0.32 10 PM TROPICANA APPLE JUICE 100%   200ml   140   34   1   SUB TOTAL 763kcal 200g 20.24g 6.24g

14. 3 D ay on Admission: Fat free soft diet TIMING MENU QUANTITY ENERGY (Kcal) CHO(g) PROTEIN(g) FAT(g) EARLY MORNING (6 AM) TENDER COCNUT WATER 200 ml 30.59   6.32   0.52   0.32 BREAKFAST (8AM) TROPICANA APPLE JUICE 200 ml   94   22.9   o.4   MIDMORNIG (10 AM) VEGETABLE SOUP 150 ml   98   12   4.1   4.4 LUNCH (1PM) DAL RICE BOILED VEGETABLES 1 cup 1 cup   293 147 48   23.19 13   5.06 5.8   3.88 TEA TIME (4PM) MILK 150 ml   109.35 7.41     4.89   6.72 DINNER (7PM) IDLY SAMBAR 4 No. 1 cup   132.09 66.56 27.28 11.09   4.68   3.98 0.34   0.49 SUB TOTAL 971KCAL 158.2g 36.7g 22g

15. 4DAY ON ADMISSION : FAT FREE SOFT SOLID DIET TIMING MENU QUANTITY ENERGY (Kcal) CHO (g) PROTEIN (g) FAT (g) EARLY MORNING (6 AM) MILK 200 ml   109.35 7.41     4.89   6.72 BREAKFAST (8AM) IDLY SAMBAR 4 No. 1 cup   132.09 66.56 27.28 11.09   4.68   3.98 0.34   0.49 MIDMORNIG (10 AM) VEGETABLE SOUP BANANA 150 ml   1No.   98 110.66  12 24.95  4.1 1.25   4.4 0.32 LUNCH (1PM) SOFT RICE SAMBAR BOILED VEGETABLE KOOTU CURD 1 cup 1 cup 1 cup   1 cup 50 ml   181.63 66.56 147 90.39 30   39.88 11.09 23.19 7.76 1.5   4.05 3.98 5.06 3.29 1.55   0.27 0.49 3.88 4.98 2 TEA TIME (4PM) MILK 150 ml   109.35 7.41     4.89   6.72 DINNER (7PM) IDLY UPMA SAMBAR 2 No. 1 cup 1 cup   100.39 160.63 66.56   20.74 19.31 11.09   3.56 4.16 3.98   0.26 7.17 0.49 SUB TOTAL 1478Kcal 224.7g 53.42g 38.8g

16. SUMMARY DATE MENU ENERGY (Kcal) PROTEIN (g) CHO(g) FAT (g) 30/04/19 CLEAR LIQUID DIET 763 20.24 200 6.24 02/05/19 FAT FREE SOFT DIET 971 158.2 36.7 22 03/05/19 FAT FREE SOFT SOLID DIET 1478 224.7 53.42 38.8

17. RECOMMENDED DIET: FAT FREE SOFT SOLID DIET TIMING MENU QUANTITY ENERGY (Kcal) CHO (g) PROTEIN (g) FAT (g) EARLY MORNING (6 AM) MILK 200 ml   109.35 7.41     4.89   6.72 BREAKFAST (8AM) IDLY SAMBAR EGG WHITE 4 No. 1 cup 1 No.   132.09 66.56 17 27.28 11.09   0.2 4.68   3.98 3.6 0.34   0.49 0.1 MIDMORNIG (10 AM) VEGETABLE SOUP BANANA 150 ml   1No.   98 110.66  12 24.95  4.1 1.25   4.4 0.32 LUNCH (1PM) RICE SAMBAR BOILED VEGETABLE KOOTU 1 cup 1 cup 1 cup 1 cup   181.63 66.56 147 90.39   39.88 11.09 23.19 7.76   4.05 3.98 5.06 3.29   0.27 0.49 3.88 4.98 TEA TIME (4PM) MILK 150 ml   109.35 7.41     4.89   6.72 DINNER (7PM) CHAPATHI VEGETABLE KOORMA 3No. 1 cup   2O4.75 109.47   51.99 11.04   9.35 2.58   2.48 5.98 SUB TOTAL 1506.2Kcal 236g 50g 37.1g

18. SPECIFIC GUIDELINES A number of post surgical complication – DIARRHEA due to bile in large bowel. No standard guideline for post cholecystectomy. Fat intake is limited Use coconut oil – Medium chain Fatty acids used for energy than stored. breakdown without bile FIBER - Normalize bowel movement soluble fiber act as sequestering agent bind with bile to avoid gastritis Avoid alcohol, caffeine, citrus foods, chocolate and onion. Supplement with choline – absorption of fat & cholesterol work with bile gas & bloating.